Healthcare Provider Details

I. General information

NPI: 1962497768
Provider Name (Legal Business Name): MITZI MARIE SIEBERT NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 W 3600 S
WEST VALLEY CITY UT
84119-4715
US

IV. Provider business mailing address

7317 MARINDA WAY
SALT LAKE CITY UT
84121-4420
US

V. Phone/Fax

Practice location:
  • Phone: 801-973-9675
  • Fax: 801-973-0379
Mailing address:
  • Phone: 801-942-0944
  • Fax: 801-942-0944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number208935-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: